I am just returning from AAMC 13 in Philadelphia, which happens to be the site of the very first AAMC conference in 1876. Perhaps it is this historic backdrop which made it more poignant when AAMC President and CEO Dr. Darrell Kirch charged the audience to rise to the occasion during our most challenging time, or our healthcare system’s “moment of truth.” Between sessions on how academic health centers needed to evolve to survive healthcare reform and how medical students need to avoid the “jaws of death” from the Match, there was certainly much to fear and much to learn. In spite of this, there are always moments where it was undeniable that the future was bright. But, the most interesting moments at this meeting where when it felt like we were going back to the future.

One of those moments was sitting in on the CLER (Clinical Learning Environment Review), or the new ACGME institutional site visit process which is not meant to be scary, but helpful! As a non-punitive visit, its meant to catalyze the necessary changes needed to help improve the learning climate in teaching hospitals. This session was particularly salient for me as I transitioned from being an Associate Program Director into role of Director for GME Clinical Learning Environment Innovation about a month ago. At one point, Dr. Kevin Weiss described the CLER site visitors observing a handoff- and in that one moment, they saw the resident bashing the ER, failure of supervision, the medical students left out, and an opportunity to report a near miss that was ignored. Even though CLER is new, he made it sound like the site visitors were going back in time and nothing had changed. Have we not made a dent in any of these areas? I guess it’s probably safest to pretend like its 2003 and we need a lot more training in quality, safety, handoffs, supervision, fatigue, and everyone’s favorite…professionalism.

After being the only tweeter at times in the Group of Resident Affairs sessions, I ventured into the tweeting epicenter of the meeting at the digital literacy session. There, I not only learned about a very cool digital literacy toolkit for educators, but also got to connect with some awesome social media mavens who use technology to advance medical education. While I have access to these technophiles through Twitter (you know who you are), it was NOT the same as talking about the future of social media and medical education face-to-face. Call me old-fashioned, but connecting with this group over a meal was just what this doctor ordered. My only wish is that we had more time together…

Lastly, we went back to the future in our session showcasing the winners of the Teaching Value and Choosing Wisely Competition at both the AAMC and ABIM Foundation meeting last week. One of the recurring themes that keeps emerging in these sessions, in addition to a recent #meded tweet chat, is that the death of clinical skills (history taking and physical exam) promotes overuse and reliance on tests in teaching hospitals. Could it be that by reinvigorating these bedrock clinical skills and bringing back the “master clinician”, we could liberate our patients from unnecessary and wasteful tests? I certainly hope so…and it can’t hurt to be a better doctor. Moreover, one of the most powerful tools that was mentioned was the time-honored case report! In fact, case reports have been resurrected to highlight avoidable care in a new JAMA Internal Medicine series called “Teachable Moments.”

And lastly, in the spirit of going back to the bedside, our MERITS (medical education fellowship team) submitted a video entry to the Beyond Flexner competition on what medical education would be like in 2033. While the impressive winners are showcased here, our nostalgic entry was aptly titled Back to the Future and Back to the Bedside, and envisioned a future where all students, regardless of their year, are doing what they came to medical school to do, see patients.

As I am on service, I realized that one thing that can be easily lost in the race to take care of patients with limited duty hours – the social history. The social history is part of the admission “history and physical” that once included a myriad of information about the patient’s job, life, and habits has now “fallen into despair” becoming little more than “negative for TED”, or in other words “no tobacco, alcohol (ethanol) or drugs.”

But, there is so much more to it than that. How do they afford to pay for their housing, food, and medications? Do they have insurance? Where do they live? Who takes care of them or do they take care of someone else? Do they have friends or family living nearby? What do they like to do for fun? Given that most of the ‘discharge planning’ focuses on these elements of the social history, it seems silly that we don’t include more than just no TED.

So, when I was asked by a very astute medical student if I preferred to hear more in the social history, I said yes. The information that is usually discussed as the patient gets better and we wonder where they will go was now presented on admission, discussed as a problem just like any other medical problem. In just a few short days, we discerned that a patient who had chronic hypoxia and shortness of breath worked in a factory which likely contributes to his interstitial lung disease. Another patient who had been hospitalized for alcohol withdrawal recently broke up with a girlfriend which triggered this bout of drinking. Another patient who was a Jehovah’s Witness would rather have IV therapy for his wound infection than surgery. Another patient with repeated hypertensive crisis had skipped his medications since he could not afford them.

Given the tremendous burden of costs of medications and the complex interplay between social factors and health, it’s time that we start teaching people to take a thorough social history. Wondering what should go into a thorough social history, I first did what most physicians do – I went online. It turns out that Wikipedia has an entry on social history for medicine that starts out with the same substance abuse history. It also includes occupation, sexual preference, prison, and travel. I stumbled upon another interesting piece by a medical student in the LA Times who admits that it is easy to skimp on the social history due to the time it takes to take a complete history. After a brief foray in PubMed, A study demonstrated that internal medicine residents do not often know the social history of patients, and this worsens if the resident is more advanced in training and when the workload is higher. Then, I recalled the seminal text that is still in use today. According to the Bates Guide to History and Physical Examination:

The Personal and Social History captures the patient’s personality and interests, sources of support, coping style, strengths, and fears. It should include occupation and the last year of schooling; home situation and signiﬁcant others; sources of stress, both recent and long-term; important life experiences, such as military service, job history, ﬁnancial situation, and retirement; leisure activities; religious afﬁliation and spiritual beliefs; and activities of daily living (ADLs). It also conveys lifestyle habits that promote health or create risk such as exercise and diet, including frequency of exercise; usual daily food intake; dietary supplements or restrictions; and safety measures and other devices related to speciﬁc hazards. You may want to include any alternative health care practices. You will come to thread personal and social questions throughout the interview to make the patient feel more at ease.

There is another good reason to teach the social history – another study shows that those residents who took better social histories were actually perceived to be more humanistic. As others stated, “By knowing patients better—and taking better social histories—we will provide better care and will be more fulfilled and energized in our work as physicians.”

Each morning this week, I am rounding on a busy inpatient general medicine service in an academic hospital seeing real patients. Each night this week, I am also studying for the internal medicine recertification exam where I am doing countless MKSAP questions which present the diagnostic and management conundrums of “fake patients.” While there are a variety of things I could say about the process, one thing is clear- the real patients don’t ever come as neatly wrapped and easy to figure out as the pithy and succinct questions based on fake patients in the prep questions! Perhaps the most distinct differences are that real patients suffer from real problems that plague real people…and that is of course why one of the most important lessons for our medical students is that being a good doctor is more than just how well you do on a standardized exam. It is knowing how to mobilize a team and resources to tend to all of these problems in the same patient. Here are just a few ways in which the real patients we see differ from testable “patients.”

Social problems trump medical problems – Many of the patients we see suffer from poor health literacy, lack of insurance, access to safe housing, affordable healthy food, and access to healthcare outside of the hospital that prevents optimal care and treatment of their medical conditions. Understanding how to bring up and address these problems is equally important to design a customized care plan for a patient that will ensure their most optimal recovery and health outside of the hospital.

Caregiver support– Many older patients who are chronically ill are cared for by family members who suffer a lot of stress. This stress manifests in different ways and sometimes you see that sigh of relief when they come to the hospital since they are in need of as much care and support as their family member. Arranging home services and providing and ensuring caregiver support is a key part of hospital care these days.

Insurance compatibility – Most patients require services that go beyond hospital discharge, such as home IV antibiotics or short-term rehabilitation stays after hospitalization to recover. In addition, patients often require close follow up after hospitalization. Unfortunately, arranging such things for patients who are uninsured or underinsured is increasingly difficult. Perhaps this is one thing that we can hope to change with the implementation of the Affordable Care Act- lets at least hope so. But for now, it’s sometimes a guessing game how to piece together the most logical plan that will also be optimally covered.

Medical necessity – These days, patients can’t stay in the hospital to “recover” unless it meets strict criteria for inpatient admission. This process is audited by private contractors so hospitals are required to follow strict guidelines or face harsh penalties from Medicare. The challenge is that for a variety of social issues documented above, patients may not be ready to go home (caregiver not ready, patient lacks understanding regarding illness, etc.) but they have to go home or be faced with footing the bill for their stay. Given that rock and a hard place, it’s a difficult position for any doctor to be in.

Because medicine does change and evolve very quickly, we refresh our medical knowledge every 10 years by testing our clinical acumen through ‘caring’ for fake patients on a written exam. But, a written exam can only go so far…Given the sea changes occurring on a daily basis in our healthcare delivery system, it is equally important to stay up-to-date on systems-level changes that influence how we can actually provide care for real patients. After all, both are necessary for good doctoring.

At the beginning of last week, I was excited to be invited to take part in the ABIM Foundation Summer Forum, where the who’s who in medicine convened to discuss how to create a sustainable healthcare system, where costs are controlled and quality of care is preserved. We heard some bold vision and ideas, many of which were focused on badly needed policy levers or system redesign. However, as I ended my week on Sunday with investing Pritzker’s new medical student class with their white coats, I was wondering how we can teach and empower individual trainees to do their part. As our speaker highlighted so eloquently, the most powerful thing about the white coat is what and who is in it…and also the learning that takes place in it. So, in that vein, here are some thoughts for what students and residents can do.

Read up on the topic – some excellent resources I heard about at the meeting

Less is More Series – a great resource in Archives of Internal Medicine edited by Rosemary Gibson and others.

Listen to the patient Of course, this sounds simple…but the truth is that more times than not, the answer is in the patient history. With duty hours and workload, taking a detailed history sometimes takes a backseat to reviewing the electronic iPatient. One approach is to start with two open questions: (1) Tell me about yourself; and (2) What are your healthcare goals? Often, the key is to try to understand the baseline. I once took care of an older patient who had abdominal pain and had received over 40 abdominal CTs over the past several years. When we were able to gather more information from the patient and her family, it turns out that she has had bad abdominal pain for over 30 years that would come and go! By working this information into her discharge summary and plugging her into primary care, our hope was to have her avoid future costly and harmful workups. As I’ve mentioned before, students often have more time with patients than residents or attendings and can often take the most helpful and detailed history!

Learn the physical exam Often times, we rely on tests since we do not trust our physical exams. It is too easy to get an echo when you are wondering if you are truly hearing a murmur. The lore here is that you need to listen to a lot of normals to be able to detect the abnormal. Because of this, when I am on service, I usually invite the third year student to examine every patient with me so they can see a lot of exams. Usually by the end, they are more confident in their ability to detect crackles or murmurs. As stated by our white coat speaker, the stethoscope is indeed a powerful tool. Interestingly, with the infectious increase in global health experiences among medical students and residents, working in resource poor settings requires ingenuity and reliance on the lowest technologically feasible solution. Closer to home, volunteering in a free clinic is likely to provide one with the same experiences.

Don’t just check boxes but ask why the test is indicated Trainees can ask the difficult question – why are we ordering this test or medication? Is it indicated? An even better question to research is whether there is a CHEAPER (we can’t shy away from using that word anymore) alternative that would provide the same information? For example, before every PE protocol CT or Doppler to rule out DVT, I always ask my team to calculate the Wells score so we understand if the test is indicated and what our pretest probability is. In addition, every study has a downside, whether it be hospital-acquired anemia from phlebotomy or incidentalomas and pseudodisease from excessive imaging. It is easy to check boxes, it is harder to question why you are checking them.

Try to find out how much the test costs While the answer is elusive, the goal is to start the conversation in your own backyard. There are anecdotal reports of residents going back over 10 years who have tried to work with their hospital billing departments to find out how much things cost. Moreover, greater knowledge of costs will change practice patterns as we’ve discussed before.

Counsel patients One impressive thing about the ABIM Foundation Forum was the representation of patient advocacy groups who were willing to partner with physicians and physician groups to reduce the costs of care. While the image that may immediately come to mind most is of a patient coming in to request a test that is not indicated, engaged and informed patients expressed the desire to work together and that less is more. In some communities, there is a lot of distrust of the medical care system and these conversations have to start one patient at a time.

Unfortunately, whittling healthcare costs is not as easy as teaching trainees. As long as our systems and the faculty within them promote costly workarounds such as misrepresenting tests as urgent to expedite them, ordering tests as fast as possible for fear of discharge delay, or wasteful lab testing, trainees will be reprimanded for NOT doing something. Therefore, to truly make change in our teaching hospitals, we must also ask that our faculty reach deep into their own white coats and find the courage to say “Don’t just do something, stand there.”

Congratulations to all of our MS2 who recently took the dreaded USMLE 1 Exam! Unfortunately, much of medical school is about memorization – and believe it or not, there is a science to memorization. I learned this from one of our students—who describes her experience meeting a ‘memory champion’ and picked his brain for some memory tricks for Step 1 including cartoon images. As I’ll be speaking at the upcoming Comics in Medicine conference here in Chicago this weekend, it seemed fitting to describe her journey.

Right around the time I was beginning an epic five-week studying stint to prepare for STEP 1 of the Boards, Joshua Foer happened to be a guest on The Colbert Report (my go-to 20 minute study break). Joshua Foer is this ridiculously young and talented journalist who won the US Memory Championships (yes this exists). If his name sounds familiar you may be thinking of Jonathan Foer, his equally talented older brother who is also a writer.

Anyway, Joshua Foer was promoting his recently released book “Moonwalking with Einstein: The Art and Science of Remembering Everything.” The book is about memory and his adventures in the world of memory competitions. Apparently there is a small group of people who get together each year and have memory competitions which consist of several memory “events” including faces of strangers, poetry, random words, numbers, binary digits, stacks of cards, etc. Participants wear noise cancelling headphones and blinders (think sunglasses with two little holes drilled out) to reduce distractors as much as possible. After attending the US competition as a journalist he wound up being tutored by and English memory master and winning the completion the next year (the US memory scene is not very developed, the Germans are much more serious).

Foer stressed that memory champions are not born with extraordinary powers of memory. They training themselves to use some established memory techniques and are constantly developing new ways on remembering things. This intrigued me since I wondered if I could use some of these techniques to master the overwhelming volume of facts needed for the Boards. I started reading his book and loved it. It’s very pop-science quick read. When chatting with one of my best friends who was studying for the Bar, she says, “Oh Josh Foer is giving a talk at this spot in Echo Park this weekend, let’s go pick his brain for ideas.” (I studied in LA).

So we went… and I managed to get up the nerve to ask him for any advice. In the most bizarre coincidence, he tells me that his wife is a also second year medical student studying for the boards (bet she’ll do just fine!). Since visual mnemonics are big in the memory world, he explained that when making a visual aid, the funnier, scarier, raunchier, and stranger it is, the easier it is to remember. He recommended trying to enrich the image with as much detail as possible. He also explained that, though these images help you remember, thinking up good ones takes a lot of creative energy and can be exhausting. That’s one of the things you work on developing when training for a memory championship – the capacity to conjure up rich, creative images really quickly. He signed my First Aid for the Boards, and I went home and started using that idea by making cartoons (a la Micro Made Ridiculously Simple).

He was right…creative effort is draining. Sometimes, it took forever to think of something that would stick – but the stuff I made cartoons for is in the vault! Here is an example of a visual aid I made myself for a mucopolysccharidosis, Hurlers. In this image there is a gargoyle (Hurler’s causes gargoylism) hurling a ball (Hurler’s). He has a dark spleen and liver (spleno- and hepatomegaly) and rain clouds for eyes (clouded corneas). He is also panting and gasping because of airway obstruction. What I love about this picture is that if I can remember one part of the image (one thing about Hurler’s) the rest of the image (the rest of the facts) come back to me. The other nice thing I noticed is that on a lot of Boards questions you narrow it down to two answers, but it’s been a while since you looked at that material and you are 70% sure you picked the right answer. If I made a picture like this I was sure, clouded cornea’s goes with Hurler’s, not the related Hunter’s disease. I used some other techniques from the book: the “memory palace” for biochemical pathways; the “major system” to remember lab values. While memory tricks don’t lend itself to everything, it was really helpful for stuff that is difficult to reason through (lysosomal storage diseases, embryology).

–Gabrielle Schaefer, MS2

Thanks to Gabrielle for describing her experience! And who said doodling in class never got you anywhere?

This past weekend, I gave a talk at the Committee of Interns and Residents, the largest housestaff union in the United States. The most inspiring moment of the meeting that I witnessed were the 2 standing ovations earned by Dr. Koffler for advocating for residents to get paid in 1936 (her first paycheck was 15 dollars a month!). How could I follow that…especially with a talk on how to train cost-conscious physicians? Those who know my work well may even wonder how I got invited to talk about this. Well, earlier this December, I wrote on the blog about my holiday wish list for medical education and #2 was a curriculum on cost conscious practice for medical trainees. In addition to lack of a formal curriculum, there were several other barriers on teaching residents how to practice cost-conscious medicine that I discussed.

Faculty are not trained. The largest barrier of course is that faculty don’t know how to do this. A study in Journal of Hospital Medicine showed that faculty physicians could not identify what things cost.

No one knows what the cost of anything is. Because each hospital negotiates its own prices with suppliers, it is very difficult for residents to know how much things cost. In trying to find out how much your hospital charges for various tests, you may end up on a wild goose chase until you find the helpful person who may or may not even be in your state!

Bad systems promote costly workarounds. Most of the time, residents are too concerned that they won’t be able to get a test or worse, it will delay a patient’s discharge. The system is set up to order the test even if the attending thinks about it. Some of our own data shows that interns learn during internship to misrepresent tests as urgent to get the job done.

Rumors and hospital legends spread quickly. The highly connected residency program can actually spread rumors about how much things cost or give rise to urban legends when patients actually pay and don’t pay.

Underordering, not overordering, is penalized. Due to the highly litiginous environment, most attendings encourage residents to err on the side of getting a test since the biggest fear we all have is of missing the ‘can’t miss’ diagnosis. More reasons doctors over-order tests here.

So what can we do to teach residents about cost-conscious practice? Well here are just a few of the things we can do..

Empower residents to find out how much their hospital charges for things. As I said at the conference, we may need to start a support group for those that start down this daunting path – but it is the first step to understanding how to control costs. Starting with senior leadership could be helpful – after all, how many C-suite leaders would not want to find out how to teach residents to control their costs? There is also a related movement to improve price transparency for patients.

Show residents how much they spend. At least in the case of daily phlebotomy, a recent study dubbed “Surgical Vampires” (due to the daily blood draws ordered by the surgical interns) highlighted that letting residents know how much things cost actually reduced the cost of lab ordering per patient and resulted in 50,000 dollars saved over 11 weeks! Studies with electronic health records at the point of care show even greater results!

Incorporate discussions of costs into routine educational conferences. At Harvard, one chief resident started a Hospital Bill Morning Report for the residents to review what a patient bill is like. In our medical student lectures on radiology, the costs of the tests are also now discussed.

Educate patients that less is sometimes more. Letting patients know about the risks of overordering tests- specifically workups of incidentalomas and pseudodisease may be helpful in explaining your new approach to cost-conscious medicine. The pushback from patients may be the fear of rationing, which is of course irrational since it already occurs. A helpful summary for patients on high value cost conscious medicine appeared in Annals of Internal Medicine.

As with all things, there is the potential for unintended consequences in teaching cost-conscious medicine. The most egregious of which would be to hide behind the veil of practicing cost-conscious medicine in order to shirk work and avoid getting an indicated test when needed. This is especially important to watch out for as burnout sets in late in the academic year. So, as we resist our inner vampire urge to order blood tests and uncover hospital urban legends and myths about healthcare costs, its equally important not to morph into the haphazard and dangerous cost-cutting monsters that we all fear most.

During my last two weeks on service, whenever we ordered an MRI or a CT, I wondered was this scan necessary and will it really change care? In addition to increasing scrutiny on the perils of unnecessary radiation, the blogosphere was abuzz about this topic (see Bob Centor and Bob Wachter among others). Coincidentally, our grand rounds speaker last week was Dr. Bruce J. Hillman who is the chief of the Journal of the American College of Radiology, and recently coauthored a book on the subject titled the Sorcerer’s Apprentice: How Medical Imaging is Changing Health Care.

Many of Dr. Hillman’s observations were spot on – radiologists hedge – they overcall things due to concerns they will miss something. An overcall is better tolerated than a miss. As a result, many patients are diagnosed with incidentalomas or pseudodisease that could lead to other costly workups and expose them to unnecessary radiation. How can a clinician ‘ignore’ the overcalled incidentaloma in the world of malpractice? Dr. Hillman also spent a lot of time discussing the overreliance on scanning in teaching hospitals. In the busy overworked environment in many hospitals, it is easier to get a scan than do a thorough history and physical exam. (This is assuming that physical exam skills are actually good enough to pick things up).

Unfortunately these days, residents actually have LESS time for history and physical. With duty hours, the chance they actually met a patient on admission and obtained the history is lower. There is also less time to make a decision. With pressure for shorter length of stays coupled with system inefficiencies, if you’re not in the queue the day before for the imaging test du jour, you will add on an extra day just to get the test. Lastly, while fear of litigation does play a role, physicians also worry about backseat quarterbacking and looking bad in front of peers. For example, I often thing to myself, if this patient comes back to the ED with the same complaint, would those physicians think I was crazy for not getting a scan? Because imaging often helps make the right call, the question is when is it appropriate or inappropriate?

This is when radiologists have traditionally come in. When I was a resident, I recall going down to radiology and asking the film clerk to get my films (in fact, being friends with the film clerk was as important as being friends with the nurse). After waiting patiently in line in the dark room for the next available radiologist in the specialty of interest, I ‘presented’ the patient with a one liner and the specific clinical question. The radiologist would then reread the films and discuss the case, often asking for more questions. At the end of this conversation, I often had a plan which usually did not involve another scan.

While technology has replaced our trusty film clerk as our greatest friend, it has also become our worst enemy. Today, I can look at images on the computer, even on the iPads that our residents carry on rounds, and eagerly await the ‘final read’ by the attending. Ordering tests has also become easier. Most of my time as an intern was spent calling down to radiology convincing them I needed the test. That is in sharp contrast to today when orders are just entered electronically with a drop down selection of ‘reasons’ that include ‘r/o pneumonia’ or ‘dyspnea’ (fancy medical term for shortness of breath). No wonder most of the reads come back as “suggest clinical correlation.”

So, how do we fix this? Well, Dr. Hillman highlighted the need to start early in training – essentially to teach students and residents to do this better. So, this past week at a curriculum meeting, I was pleased to learn that one of our expert radiologists would be formally integrating radiology into our third year IM clerkship, including costs of testing and appropriateness of tests. However, we all know this will not change anything if the faculty are pushing for the scans. Professional organizations have recognized this, and started to offer guidelines for practicing physicians. Earlier this month, the American College of Physicians released guidelines calling for internal medicine physicians to minimize scanning for low back pain. The American College of Radiology has released “appropriateness” criteria for a variety of clinical conditions which include the radiation risk for each test. Since faculty may or may not see guidelines, Massachusetts General Hospital has gone one step further, embedding these criteria into the electronic ordering system for radiology testing as a hard stop, which offers suggestions for low yield exams and require that a physician override the system to proceed. Indeed, technology can be a better friend. Perhaps, another solution is to talk to our old friend the radiologist.